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You are now watching: 7 golden rules of echocardiography 1. Echo is an art, so practice! In order for you to become an expert, you need to practice, practice, practice. But how do you know if your reports are true and valid? This question takes us straight to the second rule… 2. Get an adviser to guide your way. Mentors are important for two reasons: Firstly, they can correct and assist you in your clinical judgment. Secondly, they will guide your echo practice. 3. Be interested and always ask “why”. Curiosity is one of the driving factors of successful diagnosticians. always ask why…“Why is the ventricle enlarged?” – “Why is the jet eccentric?” – “Why is RVF poor?” – “Might this be PE ?” etc. Also: play around! Use abnormal views and see what happens when you manipulate the transducer.

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4. You are allowed to talk to the patient! This will ease the patient and make the exam more pleasant. 5. Study cardiology and cardiothoracic surgery. Put yourself into the driving seat of patient management. Your echocardiogram is often key to the treatment strategy. 6. Measure and quantify but only trust reliable values. Everybody likes facts and numbers to base decisions on. However, many studies have found that eyeballing performed by an experienced echocardiographer is just as good, if not better, as a measurement. 7. Store digitally and compare with previous studies! That’s what radiologist do all the time. You can easily miss subtle changes simply based on measurements, which have a large measurement error. Left ventricular function and pericardial effusion are good examples. The eye will give you a better appreciation. If you can stick to these rules, your echo skills will significantly improve.

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Major Factors That Affect Flow Across Any Valvular Lesion The valve area The square root of the hydrostatic pressure gradient across the valve The time duration of transvalvular flow (applies to both systole and diastole)

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Valvular Heart Disease Increasing any of the major factors that affect flow across the valve increases transvalvular flow. Conversely, decreasing any of these major factors decreases transvalvular flow.

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Goals in Management of Various Valvular Lesions Regurgitant Lesions –Reduce or minimize regurgitant flow across the mitral or aortic valve. Stenotic Lesions –Maximize and enhance stenotic flow across the mitral or aortic valve

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The valve area in regurgitant lesions can respond to changes in loading conditions (preload, afterload) The valve area with stenotic lesions is generally fixed Goals in Management of Various Valvular Lesions

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Pathophysiology LV “unloads” itself into left atrium –Chronic left atrial overload Chronic overload on left ventricle Volume of regurgitant flow determined by: –Ventriculo-atrial gradient –Diastolic time –Size of the regurgitant orifice Measurements of LV function tend to be slightly elevated –Moderately depressed ejection fraction in a patient with MR may be indicative of a severely depressed inotropic state

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Illustration of the variation of the PISA and hence ERO during systole. In early and late systole, closing forces are relatively low and so the ERO and PISA relatively large. In midsystole, coincident with peak regurgitant velocity closing forces are maximal and so the ERO and PISA contract as the tips of the leaflets are forced closer together.

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CW Doppler of MRJ Peak MR jet velocities by CW Doppler typically range between 4and 6 m/s. This reflects the high systolic pressure gradient between the LV and LA. The velocity itself does not provide useful information about the severity of MR. Conversely, the signal intensity (jet density) of the CW envelope of the MR jet can be a qualitative guide to MR severity. A dense MR signal with a full envelope indicates more severe MR than a faint signal. The CW Doppler envelope may be truncated (notch) with a triangular contour and an early peak velocity (blunt). This indicates elevated LA pressure or a prominent regurgitant pressure wave in the LA due to severe MR. In eccentric MR, it may be difficult to record the full CW envelope of the jet because of its eccentricity, while the signal intensity shows dense features.

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Consequences of mitral regurgitation The presence of severe MR has significant haemodynamic effects, primarily on the LV, LA and SPAP.

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LV size and function The LV dimensions and EF reflect the heart’s ability to adapt to increased volume load. In the chronic compensated phase (the patient could be asymptomatic), the forward SV is maintained through an increase in LVEF. Such patients typically have LV EF 65%. In the chronic decompensated phase (the patient could still be asymptomatic or may fail to recognize deterioration in clinical status), the forward SV decreases and the LAP increases significantly. The LV contractility can thus decrease silently and irreversibly.

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However, the LV ejection fraction may still be in the low normal range despite the presence of significant muscle dysfunction. current guidelines, surgery is recommended in asymptomatic patients with severe organic MR when the LV ejection fraction is ≤60%. In the end-systolic diameter.45 mm (or ≥40 mm or.22 mm/m2, AHA/ACC), also indicates the need for mitral valve surgery.

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A systolic tissue Doppler velocity measured at the lateral annulus,10.5 cm/s has been shown to identify subclinical LV dysfunction and to predict post-operative LV dysfunction in patients with asymptomatic organic MR. Strain imaging allows a more accurate estimation of myocardial contractility than tissue Doppler velocities.

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Left atrial size and pulmonary pressures The LA dilates in response to chronic volume and pressure overload. A normal sized LA is not normally associatedwith significantMR unless it is acute, in which case the valve appearance is likely to be grossly abnormal. LA remodelling (diameter 40–50 mm or LA volume index.40 mL/m2) may predict onset of AF and poor prognosis in patients with organic MR.

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Conversely, MV repair leads to LA reverse remodelling, the extent of which is related to preoperative LA size and to procedural success. The excess regurgitant blood entering in the LA may induce acutely or chronically a progressive rise in pulmonary pressure. The presence of TR even if it is mild, permits the estimation of systolic pulmonary arterial pressure. Recommendation for mitral valve repair is a class IIa when PASP is 50 mm Hg at rest.

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Key point When MR is more than mild MR, providing LVD, LVV, LVEF as well as the LAD (preferably LAV) and the PASP in the final echocardiographic report is mandatory. The assessment of regional myocardial function (systolic myocardial velocities, strain, strain rate) is reasonable particularly in asymptomatic patients with severe organic MR and borderline values in terms of LV EF(60–65%) or LV ESD (closed to 40 mm or 22 mm/m2).

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Key point Exercise echocardiography is useful in asymptomatic patients with severe organic MR and borderline values of LV ejection fraction (60–65%) or LV end-systolic diameter (closed to 40 mm or 22 mm/m2). The absence of contractile reserve could identify patients at increased risk of cardiovascular events. Moreover, exercise echocardiography may also be helpful in patients with equivocal symptoms out of proportion of MR severity at rest.